10 Future Directions

10.1 Future Directions

Despite being very common, it is still clinically challenging to manage patients with WAD.¹ Since WAD can involve a long course, it is a true example of how a chronic pain condition should be viewed from a bio-psycho-social perspective;² it impacts a patient from all three dimensions, either directly or indirectly. Despite the advances that have happened, further research and work on mechanisms underpinning persistent pain and disability and therapeutic elements are very likely to impact clinical management.

Future Directions

Research on transition from acute to chronic WAD: Whiplash injury clearly marks the beginning of the disorder. However, because of the range of acute injury presentations, and their heterogeneous nature, it has not been possible to identify factors that predispose to chronicity of this disorder. Priorities such as injury-prevention strategies (i.e., vehicle design); effectiveness and timing of early pain management; development of content and delivery of educational information for those with acute whiplash; testing the efficacy of rehabilitation and psychological modalities; and researching modes of delivery considering psychosocial modulators of pain and disability should be considered.³ It is appropriate that the Canadian Institutes of Health Research (CIHR) Institute of Musculoskeletal Health and Arthritis (IMHA) has identified better causal mechanisms of pain as one of the three priority foci of their most recent strategic plan.⁴

Psychological and social determinants: Established maladaptive pain behaviors that develop within the first weeks after the injury could explain a significant part of the transition from acute to chronic WAD. In that direction, therapy targeting psychological risk factors such as pain catastrophizing, fear-avoidance beliefs, depression, and symptoms of PTSD could be important in preventing the development of chronic WAD.⁵ However, a largely ignored aspect is the influence of possible blame factor and perceived feeling of injustice from a medico-legal and social perspective, on the development of whiplash.^6,7 This is especially important, as prevalence of WAD is different from country to country.

Guidelines to practice and effective knowledge translation: There are several existing guidelines or task force recommendations on the management of a whiplash injury patient.^8-10 However, uptake and implementation of these guidelines by physicians and health providers is limited and inconsistent.^11,12 It is important to identify challenges and barriers to uptake and implementation so effective knowledge translation strategies, tools, and resources engage clinicians and the public to appropriate action. It is important to engage patient group stakeholders to better understand and integrate self-care models that patients can find acceptable.

Role of medications and interventions: The role of medications and interventions in patients of whiplash are primarily to decrease pain, thereby allowing for improved function and activities. Effective management of pain potentially can also influence the depression or PTSD by reinforcing a belief of control and allowing for self-care. Many questions remain unanswered: what is the delivery and timing of early pain intervention? What is the evidence supporting the long-term use of medications for persisting pain? Among percutaneous interventions, for patients with chronic WAD who do not respond to conventional treatments, it appears that radiofrequency neurotomy may be the treatment option of choice.¹³ However, the evidence is supported by small studies and further evaluation of its effectiveness within the scope of interdisciplinary treatment must be considered. Likewise, very little evidence exists to support the use of botulinum injections to help with chronic neck pain or headache in patients with WAD,¹⁴ despite the widespread practice. Further research also is needed to support complementary techniques such as acupuncture.¹⁵

Role of interdisciplinary therapy: It is clinically reasonable to take a multidisciplinary approach.¹⁶ That being said, a number of RCTs have shown conflicting results.^13,17 Interdisciplinary care integrates services at one site, and facilitates greater communication and interaction among disciplines. For those with higher risk of poor prognosis at the onset of a whiplash injury, a multimodal approach includes pharmacotherapy, psychological approaches, physical therapy, and educational interventions.¹⁸ However, what components should be included in a multidisciplinary therapy, and what are the critical or noncritical components of the therapy are still very unclear. Even within, whether the components should be tailored to each patient,¹⁷ or whether it should be similar is not clear.⁹ Exercise and rehabilitation therapy has shown positive results in many studies.^13,19 Focusing on patient-perceived limitations and improvement in activities of daily living, coupled with psychological desensitization, has shown promising results in the longer run.^19,20 Knowledge of multidisciplinary care within and between centers enables greater communication and provision of care.²¹  

10.2 References

1. Ferrari R, Kwan O, Russell AS, Pearce JM, Schrader H. The best approach to the problem of whiplash? One ticket to Lithuania, please. Clin Exp Rheumatol 1999;17:321-6.
2. McLean SA, Clauw DJ, Abelson JL, Liberzon I. The development of persistent pain and psychological morbidity after motor vehicle collision: integrating the potential role of stress response systems into a biopsychosocial model. Psychosom Med 2005;67:783-90.
3. Jull GA, Soderlund A, Stemper BD, et al. Toward optimal early management after whiplash injury to lessen the rate of transition to chronicity: discussion paper 5. Spine 2011;36(25 Suppl):S335-42.
4. Walton DM, Elliott JM, Lee J, et al. Research priorities in the field of posttraumatic pain and disability: results of a transdisciplinary consensusgenerating workshop. Pain Res Manag 2016;2016:1859434.
5. Andersen TE, Ravn SL, Roessler KK. Value-based cognitive-behavioural therapy for the prevention of chronic whiplash associated disorders: protocol of a randomized controlled trial. BMC Musculoskelet Disord 2015;16:232.
6. Ferrari R, Russell AS. Why blame is a factor in recovery from whiplash injury. Med Hypotheses 2001;56:372-5.
7. Sullivan MJ, Adams H, Martel MO, Scott W, Wideman T. Catastrophizing and perceived injustice: risk factors for the transition to chronicity after whiplash injury. Spine 2011;36(25 Suppl):S244-9.
8. Bussieres AE, Stewart G, Al-Zoubi F, et al. The treatment of neck painassociated disorders and whiplash-associated disorders: a clinical practice guideline. J Manipulative Physiol Ther 2016;39:523-64.e27.
9. Sutton DA, Cote P, Wong JJ, et al. Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J 2016;16:1541-65.
10. Carroll LJ, Cassidy JD, Peloso PM, et al. Methods for the best evidence synthesis on neck pain and its associated disorders: the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine 2008;33(4 Suppl):S33-8.
11. Brijnath B, Bunzli S, Xia T, et al. General practitioners knowledge and management of whiplash associated disorders and post-traumatic stress disorder: implications for patient care. BMC Fam Pract 2016;17:82.
12. Kendall E, Sunderland N, Muenchberger H, Armstrong K. When guidelines need guidance: considerations and strategies for improving the adoption of chronic disease evidence by general practitioners. J Eval Clin Pract 2009;15:1082-90.
13. Teasell RW, McClure JA, Walton D, et al. A research synthesis of therapeutic interventions for whiplash-associated disorder (WAD): Part 4 – noninvasive interventions for chronic WAD. Pain Res Manag 2010;15:313-22.
14. Langevin P, Peloso PM, Lowcock J, et al. Botulinum toxin for subacute/ chronic neck pain. Cochrane Database Syst Rev 2011(7):CD008626.
15. Moon TW, Posadzki P, Choi TY, et al. Acupuncture for treating whiplash associated disorder: a systematic review of randomised clinical trials. Evid Based Complement Alternat Med 2014;2014:870271.
16. Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling M. Management of acute whiplash: a randomized controlled trial of multidisciplinary stratified treatments. Pain 2013;154:1798-806.
17. Ruan X, Kaye AD. A call for saving interdisciplinary pain management. J Orthop Sports Phys Ther 2016;46:1021-3.
18. Pergolizzi J, Ahlbeck K, Aldington D, et al. The development of chronic pain: physiological CHANGE necessitates a multidisciplinary approach to treatment. Curr Med Res Opin 2013;29:1127-35.
19. Southerst D, Nordin MC, Cote P, Shearer HM, Varatharajan S, Yu H, et al. Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Spine J 2016;16:1503-23.
20. Ehrenborg C, Gustafsson S, Archenholtz B. Long-term effect in ADL after an interdisciplinary rehabilitation programme for WAD patients: a mixedmethod study for deeper understanding of participants’ programme experiences. Disabil Rehabil 2014;36:1006-13.
21. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol 2014;69:119-30.